Microsoft powerpoint - leadershipforumpresentation_6-27-11_kg.ppt

Leadership Forum:Monitoring Psychoactive Medication Use in ChildrenLaurel K. Leslie, MD, MPHTufts Clinical and Translational Science InstituteTufts Medical Center Floating Hospital for ChildrenKatherine E. Grimes, MD, MPHChildren’s Health Initiative/Cambridge Health AllianceHarvard Medical School
 Evolving patterns of use; both more meds and
 Changes in health and mental health care
system; greater fragmentation, less oversight; change in role and training of prescribers
 Limited information about efficacy of combined
 Insufficient research on how new psych meds
work or effects on health from long-term use
Changing prescription rates in youth have led to concerns about :
 increasing likelihood of co-prescription
 adverse effects from drug interactions
 Medications prescribed for emotional/behavioral
 Also termed “psychoactive” or psychiatric meds;
some meds may impact both physical and mental conditions
 Use of more than one psychotropic medication
 Use of 4+ meds within or across drug classes
Some Common Classes of Psychotropic MedicationsClass NameIndicationsExamples
 Psychotropic medication use increased 2-3
 Among privately insured very young children
(2-5 years old), psychotropic medication use increased about 2-fold (Olfson et al, 2010)
 Polypharmacy increased 2.5-8 fold (Olfson et
 Increasing use of newer medications just
coming to market or medications being used “off-label”
 multiple vulnerabilities making their care
 limited agency in decisions regarding
risk of disparities in access to appropriatemedication and in medication use.As cited in NYT (12/11/2009): Crystal et al, 2009Use by Children in Foster Care
 Estimated rates of medication use for children in
foster care range from 13-52% as opposed to 4% in general population. (dosReis et al., 2001; Kansas Health Policy Authority, 2008; Raghavan et al., 2005; Zima et al., 1999)
 State-variation in use of 3 + psychotropic
medications for children with Autism Spectrum Disorder in foster care (Rubin et al., 2009)
 Random sampling of 472 children in foster care in
Texas found 41% received three or more psychotropic drugs at the same time (Zito et al., 2008)System (Dis-)CoordinationMental HealthJudge & Providers TherapistTo ParentsProbation Clinician(s)Foster ParentsBiological CBHI in MACommunityParent(s)Child or ProgramsAdolescentAdoptiveWorker(s)Parent(s)AgenciesTeacher(s) & AffiliatedSchool Staff ResidentialHospitalInterventionPsychiatrist
 Delivery system changes have attenuated direct
psychiatric contact and increased prescribing-by-proxy for children and adolescents.
 Insurance changes mean few psychiatrists can
see patients for therapy; psychiatric care is likely to be discontinuous (role reduced to “the psychopharm”).
 Unfamiliar clinicians are more likely to add to,
rather than reduce, the numbers of medications being given when faced with a symptomatic child. Expanded “indicators” (Penn, 2006).
Limited Information about Meds in Children
Phase I: What are safe doses and common side effects?
Phase III: Is the drug better than standard care? (often ‘placebo’)
Phase IV: What else can we learn from post-marketing studies about medication risks, benefits, and optimal use?
Congress to Begin Investigation into SSI for ChildrenOn behalf of Disability Rights Law Center- Alex Boudov, Attorney at Law posted in Supplemental Security Income on Friday, January 21, 2011Last month, we extensively discussed the many perceived problems with the Social Security Disability and Supplemental Security Income programs for children. Specifically, it is alleged that the allure of the monthly income and free medical care has motivated parents to place their children on psychiatric drugs they do not need because they think that being prescribed such medication is a near-requirement for qualification. In addition, we examined the increase of children qualifying for SSD and SSI based on mental, behavioral and learning disorders, and how that number has increased from 8 to 50 percent of all children receiving SSD or SSI in the past 20 years.Following the detailed news articles that gave rise to our blog posts, several members of Congress took notice of the alleged problems with the children's programs, and have pledged to launch an investigation into them. Currently, the federal children's disability programs have an average annual price tag of $10 billion, and they are quickly growing in both size and cost.
 New information about adverse effects
supports ongoing assessment of efficacy vs. risk in psychotropic use
 Prescribing trends for distinctly vulnerable groups
 Variation in prescribing patterns by clinician
specialty, insurance type, etc. may contribute to health care disparities for certain groups
 Identifying the gap between the evidence base for
psychotropics and prescribing practice patterns can help define training needs
Changing Federal Oversight of Medication Use in Children
 1994- FDA proposes increasing study of medications in
 1997-FDA Modernization Act (FDAMA): market exclusivity incentive if voluntarily conduct studies in children
 2002-Best Pharmaceuticals for Children Act (BPCA): mandated 1 year post-marketing surveillance and reporting of adverse events FDA forms Pediatric Advisory Committee
Capturing prescribing trends creates a basis
 measurement of the congruence between
provider practice patterns and the evidence base
 identification of system enhancement
opportunities (i.e. electronic records) to protect youth from unnecessary risk
 information to support clinician training to
ensure that children get the maximal opportunity to benefit from medication
 Rosie D. remedy/ Children’s Behavioral
 Medicaid-Mental Health Collaboration on
Psychoactive Medications in Children Workgroup
Challenges
 Delivery system model (carve-outs) increases
 Workforce capacity issues; both the cause and the result
 Lack of self-policing among professional groups
Opportunities Increased focus on links between mental health status
and overall child outcomes (i.e. “ACE” study)
 Families and purchasers asking for evidence-based
 Health care reform (parity?); new quality standards
 Conducted a national study of 47 states
1) Examined state policies and best practices
disseminate to other child welfare agencies
 Attention to consequences of flags (“any teeth at
 trigger feedback by prescriber patterns?
 Feedback triggered by patient med use?
 Need to monitor if children are getting MH
 Multiple possible links to fed government activities
 Strategies for increasing awareness of the issue
 Importance of creating career opportunities so that
clinically trained child mental health workforce is available to meet the needs of youth and families
 Learn what we know about medication use in
 Learn what we know about medication use in
 Consider how we can better use the data we
have to improve care (Leadership Forum Participants)
 Identify some next steps (Leslie and Grimes)
 DosReis, S., Zito, J., et al. (2001). Mental health services for youths in
foster care and disabled youths. American Journal of Public Health, 91(7), 1094-1099.
 Kansas Health Policy Authority. Medicaid Transformation Report
2008.http://www.khpa.ks.gov/medicaid_transformation/download/2008/KHPA_2008_Medicaid_Transformation.pdf
 McClellan, J. & Werry, J. (2003). Evidence-based treatments in child
psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 42(12), 1388-400.
 Olfson, M., Marcus, S.C., et al. (2002). National trends in the use of
psychotropic medications by children. Journal of American Academy of Child and Adolescent Psychiatry, 41(5), 514-521.
 Olfson, M., Crystal, S., et al. (2010). Trends in antipsychotic drug use
by very young, privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry, 49(1), 13-23.
 Cascade, E., et al. (2006). Recent Changes in Prescriptions for
Antipsychotics in Children and Adolescents, Psychiatry, 3(9), 18-20.
 Raghavan, R., Zima, B., et al. (2005). Psychotropic medication use in a
national probability sample of children in the child welfare system. Journal of Child and Adolescent Psychopharmacology, 15, 97–106.
 Rubin D., et al. (2009). State variation in psychotropic medication use
by foster care children with autism spectrum disorder. Pediatrics, 124(2), 305-312.
 Vitiello B, Riddle MA, et al. (2003). How can we improve the
assessment of safety in child and adolescent psycho-pharmacology? Journal of the American Academy of Child & Adolescent Psychiatry, 42, 634-641.
 Zima, B., Bussing, R., et al. (1999). Psychotropic medication use
among children in foster care: relationship to severe psychiatric disorders. American Journal of Public Health, 89(11), 1732-1735.
 Zito, J., Safer, D., et al. (2008). Psychotropic medication patterns
among youth in foster care. Pediatrics, 121(1), 157-163.

Neuron, Vol. 21, 1223–1229, December, 1998, Copyright  1998 by Cell Press Previews memory code essentially a relational code. According Linkage at the Top to this view, memory networks, after they have been formed, are defined by their cortico-cortical connectiv- ity, are exquisitely specific with regard to their content, Around the last turn of the century, neuroscientists